WE CAN KEEP YOU COVERED WORLDWIDE. fepblue.org

2021 OVERSEAS PROGR AM

Blue Cross and Blue Shield Service Beneft Plan

Table of Contents

2021 Overseas Beneft Summary ........................... 1

Using your benefts outside of the U.S.................. 3

Overseas medical benefts ...................................... 5

Getting care overseas .............................................. 6

Overseas pharmacy benefts................................... 7

Wellness programs................................................... 8

2021 Overseas Beneft Summary

The Blue Cross and Blue Shield Service Beneft Plan has been serving federal employees, retirees and their families for 60 years. One of the things that sets our coverage apart is that you can use your benefts both in the U.S. and overseas.

Here’s why federal employees choose Blue:

We have dedicated 24-hour overseas

assistance

Your coverage works no matter where you live or travel

You have access to a number of wellness

programs and discounts

We waive the Standard Option deductibles for

overseas care

When you’re overseas, we waive your copays

for inpatient care

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As with all of our members, you’ll have the option to enroll in one of our three plans:

Standard Option

Basic Option

FEP Blue Focus S B F

You’ll also have three levels of coverage to select from:

Self Only Self + One Self & Family

Throughout this booklet we will showcase how our benefts work overseas. While many of our benefts are the same no matter where you are, we do offer some benefts exclusively for members who live or travel outside of the U.S.

For more information on using your benefts within the U.S., please visit our website fepblue.org or call 1-800-411-BLUE.

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Using your benefts outside of the U.S.

You can use any licensed provider overseas. However, before you get care, we recommend that you contact our Overseas Assistance Center to arrange for direct billing. Providers who have a direct billing arrangement with GMMI accept a visit/case-specifc GOB from GMMI. You can contact the Center at 1-804-673-1678 or by emailing fepoverseas@gmmi.com.

What is a guarantee of benefts?

When a provider accepts a guarantee of benefts (GOB) from our Overseas Assistance Center (run by GMMI), they will bill GMMI directly for your covered services. This means that you will not need to submit a separate claim—we’ll handle all the processing for you!

GMMI already has over 13,000 providers with direct billing arrangements. All of these providers are listed in our overseas provider directory located at fepblue.org/provider. You can also call 1-804-673-1678.

If your provider is not listed in the directory, that doesn’t mean that they won’t accept a GOB. If you call or email our Overseas Assistance Center they will be happy to work with your providers to try and get a GOB in place. You can also complete a provider nomination form and send it to GMMI.

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What happens if my provider doesn’t accept a GOB?

If your provider does not accept a GOB, we will still pay for your covered services at the Preferred (in-network) level. However, you’ll need to pay for your care, and we’ll reimburse you after you submit a claim and associated itemized bills. To help avoid any claims delays, you should ask your provider to give you the medical records for your care. You’ll need these when it’s time to submit your claim.

Once you have your medical records and itemized bills, you can submit your claim online, by fax or by mail.

Submit online

Login or register for a MyBlue® account. Once you’re logged in, click “Submit Overseas Claim” under the Claims & Costs tab.

Submit by fax or mail

Download and complete your medical claim form or pharmacy claim form. Send the completed form and itemized bills to the correct location noted below.

Medical Claims

Federal Employee Program Overseas Claims PO Box 260070, Pembroke Pines, FL 33026

001-954-308-3957

Pharmacy Claims

Blue Cross and Blue Shield Service Beneft Plan Retail Pharmacy Program PO Box 52057, Phoenix, AZ 85072-2057

001-480-614-7674

Did you know? We offer free translation services and currency conversion to members overseas. If you receive a bill or claim in a different language, our Overseas Assistance Center will translate it for you. You can also request to have your reimbursement paid in U.S. currency or local currency.

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2021 Overseas Medical benefts Beneft Standard Option Basic Option FEP Blue Focus

Primary care doctor

$25 copay $30 copay1 $10 per visit for your frst 10 primary and/or specialty care visits1

Specialists $35 copay $40 copay

Maternity $0 copay $0 copay $0 copay

Inpatient $0 copay $0 copay $0 copay

Outpatient hospital

15% of our allowance $100 per day per facility 30% of our allowance2

Surgery 15% of our allowance $150 in an offce1

$200 in a non-offce setting1

30% of our allowance

ER (accidental injury) $0 within 72 hours $175 per day $0 within 72 hours

ER (medical emergency) 15% of our allowance copay1 30% of our allowance

Lab work (such as lab tests and EKGs)

15% of our allowance $0 copay1 $0 for frst 10 specifc lab tests3

Diagnostic services (such as sleep studies, X-rays, CT scans)

15% of our allowance Up to $100 in an offce1

Up to $150 in a hospital1 30% of our allowance2

Physical, Speech and/or Occupational Therapy

$25 at a primary care doctor $35 at a specialist

Limited to 75 visits per person a year

$30 at a primary care doctor1

$40 at a specialist1

Limited to 50 visits per person a year

$25 copay per visit

Limited to 25 visits per person a year

Deductible Waived overseas No deductible Self Only: $500 Self + One and Self & Family: $1,000

Out-of-Pocket maximum

Self Only: $5,00

0 Self + One and Self & Family: $10,000

Self Only: $5,500 Self + One and Self & Family: $11,000

Self Only: $7,500 Self + One and Self & Family: $1

*Is subject to the calendar year deductible. The deductible for FEP Blue Focus is $500 per person or $1,000 in total per family. Basic Option does not have a calendar year deductible. Certain out-of-pocket costs do not apply if Medicare is your primary coverage for medical services (it pays frst). 1You pay 30% of our allowance for agents, drugs and/or supplies you receive during your care. 2Deductible applies. In addition, you pay 30% of our allowance for agents, drugs and/or supplies you receive during your care. 3Please see the brochure for covered lab services.

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$10 per visit for your frst 10 primary and/or specialty care visits1

$175

5,00

0

2

2

hospital

Care Overseas Members overseas can visit with providers in-person, and if applicable, virtually or on the phone. Call 1-804-673-1678 to get assistance fnding in-person care overseas.

Inpatient Care

We waive the cost of inpatient care received overseas. For Standard Option, you can go to any inpatient care provider (we still recommend you get a GOB frst, so you don’t have to submit a claim). For Basic Option and FEP Blue Focus, you must visit a Department of Defense facility or a provider that has as GOB arrangement. Call 1-804-673-1678 or email fepoverseas@gmmi.com to setup a GOB.

Telehealth visits

We’re partnered with Teladoc to offer 24/7 access to general medical services to:

• Members living in the U.S., Guam and the U.S. Virgin Islands

• Members traveling outside the U.S., but live in areas with a U.S. zip code

Teladoc doctors are all U.S. board certifed and are able to treat minor illnesses and ailments, such as cold and fu symptoms. All members get their frst two Teladoc visits of the year free. You pay a low $10 (Standard Option and FEP Blue Focus) or $15 (Basic Option) copay for all subsequent visits.

You can access this service conveniently by downloading the Teladoc app on the App Store or Google Play.

New for 2021

All members, regardless of where you live, can receive virtual care from providers outside of our Teladoc network. We cover online or phone telemedicine consults provided by primary care physicians and specialists. You’ll pay the same copay for these visits that you would pay if you visited the provider in person (see our beneft chart on page 5).

Emergency Evacuation Services

We offer emergency evacuation services for members overseas. If there’s an emergency, we’ll transfer you to the nearest facility that can treat your condition. If you need these services, please call 1-888-673-1678 BEFORE you receive services. This will help prevent you from getting overcharged for the transport.

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2021 Overseas Pharmacy benefts

You can use your pharmacy benefts overseas, as well. Drugs purchased overseas must be equivalent to drugs that by U.S. federal law require a prescription. You can download our approved drug list (formulary) at fepblue.org/pharmacy.

Get your prescriptions mailed to you

You can use the Mail Service or Specialty Pharmacy Programs overseas, as long as:

You have a valid U.S. zip code.

This includes valid APO, DPO and FPO addresses

The country you live in does not restrict

the importation of drugs from

other countries

Your prescribing physician is licensed

with the U.S., Puerto Rico or the U.S. Virgin Islands

What you pay for drugs overseas (for up to a 30-day supply)

Standard Option Basic Option FEP Blue Focus

Overseas Retail Rx

15% of our allowance 30% of our allowance Tier 1: $5 copay Tier 2: 40% of our allowance ($350 max)

Mail Service Rx Tier 1: $15 Tier 2: $90 Tier 3: $125

Not a beneft unless you have Medicare Part B primary

Not a beneft

Specialty Rx Tier 4: $65 Tier 5: $85

Tier 4: $85 Tier 5: $110

40% of our allowance ($350 max)

Tier levels vary between Standard Option, Basic Option and FEP Blue Focus. Visit fepblue.org/pharmacy to learn more about our drug tiers.

Did you know? If you take a maintenance medication and you are about to go overseas for an extended period of time, you can request up to a 12-month supply of your prescription before you leave the U.S. Contact our Pharmacy Program at 1 800 624 5060 to learn more.

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Wellness Programs

As a Service Beneft Plan member, you have access to a number of health and wellness programs. Learn more about our programs at fepblue.org/healthwellness.

Blue Health Assessment

Get a health action plan you can use to live healthier. Standard and Basic Option members may also earn $50 for completing the BHA each year.

Online Health Coach

Get support and actionable steps you can take to reach your health goals or manage certain chronic conditions. Standard and Basic Option members may earn up to $120 for completing up to three eligible goals.

Routine Annual Physical Incentive Program

FEP Blue Focus members can get rewarded for getting their annual physical each year.

Diabetes Programs

If you have diabetes, keeping your diabetes in check is important. Standard and Basic Option members can receive a free digital glucose monitor and unlimited lancets through our Diabetes Management Program by Livongo®. They can also earn up to $100 for managing their A1c through our Diabetes Management Incentive Program.

Hypertension Management Program

Members with high blood pressure may be eligible to receive a free blood pressure monitor if you have a claim that supports you have high blood pressure.

Case Management

Members with certain conditions can choose to enroll in case management. Through this program, you can work with licensed healthcare professionals to help you navigate your health needs. They’ll work with you and your providers to make sure you get the support and care you need. This service is offered to members living overseas through our Overseas Assistance Center.

Please note: For certain programs, you need a valid APO, FPO or DPO address to participate or receive rewards. In addition, overseas members can use the MyBlue® Wellness Card to make qualifed medical expense purchases outside the U.S. at approved healthcare merchants, but it is more likely that you will be asked to send in your receipts to authorize the use of funds on your Card for those purchases.

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CONTACT US We’re here to assist you if you need help overseas.

Overseas Customer Service

Do you need help with things like claims fling, enrollment questions, obtaining a Certifcate of Coverage and U.S. dollar check reimbursements? Call our dedicated Overseas Customer Service at 1-888-999-9862 weekdays from 5 a.m. to 6 p.m. Eastern time.

Overseas Pharmacy Questions (available 24/7)

1-888-624-5060

Overseas Assistance Center (available 24/7)

Need help with fnding a provider overseas, direct billing or guarantee of benefts arrangements, emergency medical evacuations, translation services and more? Call our Overseas Assistance Center.

Outside the U.S. 1-804-673-1678

Within the U.S., Puerto Rico or the U.S. Virgin Islands

1-800-699-4337

fepoverseas@gmmi.com

Learn more at fepblue.org/overseas.

Stay connected to fepblue

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This is a summary of the features of the Blue Cross and Blue Shield Service Beneft Plan. Before making a fnal decision, please read the Plan s Federal brochures (FEP Blue Standard and FEP Blue Basic: RI 71 005; FEP Blue Focus: RI 71 017). All benefts are subject to the defnitions, limitations and exclusions set forth in the Federal brochures.

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